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�- RA 1864 <br />Faun Approved. OMS No. 2050-0039 <br />Please <br />print Or type. (Form aasrgnea tar use on elite (12-prt h) typewNer) <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST I CAC002613069 <br />'1- <br />888 -785 -?225 <br />FLE <br />5. Ceomarws Name and MailongAddress Generator's Site Address in different Nan mailing address) <br />Habobank N.A. 635 8 Aurora St <br />1447 1 St Stockton, C1 93203 <br />93354 <br />VA"kate, CAGenerator's <br />Phone: 209 557-8881 <br />U.S. EPA ID Number <br />6. rarxparter I Company me <br />,Advanced Chemical Transport C11IA000070540 <br />7. Tmnspoter 2 Company Name U.S. EPA ID Number <br />Close Harbors zoviroarental Sorvices, Inc. OW039322250 <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />Clean Harbors of San Jose, LLC (San Jose laeility) <br />1021 Harryeasa Sload <br />Sea Jose CA 95133 CAD0594®4330 <br />Zoe -441-0962 <br />Facltity's Phone: <br />ga, gb. U.S. DOT Description (indudkg Proper Shipping Name, Huard Gass, ID Number, 10. Containers 11, Total 12. Ung 13. Wasle Codes <br />HM and Packing Group (f ar5')) No. TypeQuantity WtNd. <br />o <br />' +:rN 3 3�t,���yy^/A'�t'L kOKi }�zn <br />p <br />fool- <br />btOy^.L" �rs9.w� I -are X:< sax Q <br />= <br />W <br />z vN�� WL�g"�AMMoN1R SalvTio n S <br />k <br />^� <br />� <br />� <br />Doe <br />SSl <br />x <br />� <br />tGT <br />3 <br />X <br />�tQStN1APtha,D�eSQ\� 3 <br />q x AZgf cu dQJ� <br />4.k 1UODa-7Add <br />� <br />Drl <br />Lis— <br />ca <br />2z <br />IM,lXrrl� O v ` <br />Special HandlingIreWClionsawl infomratlon '�' (,,, • �x%2 / (� S- off\ e A G O p3 <br />l J <br />Project Murder: CV02673-08 <br />I LGG2o' Lxls0/r1, (2Ae-001 4CNS26)`14(IxSS�i,� RAL-oo� <br />1 ,cS'/t K4L - 002- <br />0215. <br />15.GENERATOR'S/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping mune, and are classified, packaged, <br />marked and labeleclTaczrded, and are in all respects in proper condition for transport acardng to applicable International and national governmental regulations. If export shipment and 1 am the Primary <br />Exporter, I certify that the contents of this cansignmentconform to the terms of the attached EPAAcknovdedgmentof Consent q� r T-- <br />I anily that the waste rnmintization statement identified in 40 CFR 262.27(a) (g 1 am a large quantity geperator) or (b) (fit am a small quantity generator) is We4o N o¢.:"E -L-t- CI <br />General O e s rine Name ar-eer <br />IL- <br />16. Intemadwal Shipments <br />❑Import to U.S. Export from U.S. PortofentryfexR <br />= <br />Transporter signature for e-p6ts only): Date leaving U.S.: <br />w <br />17. Transporter Aclmovdedgmenof Receipt of Maledals <br />Transporrtt+er,1 PPmAeNt mem Month pqg Year <br />QTransporter <br />2 Pdntedlryped Name Signature ear <br />C <br />H <br />18. Discrepancy <br />1be. Discrepancy Induration Space ElQuantity El Type El Residue ❑Penial Rejectlan ❑ FM Reaction <br />Manifest Reference Number. <br />18b. Alternate Facf@y (or Generator) U.S. EPA ID Number <br />J <br />U <br />uE <br />w <br />Fad' s Phone: <br />18d.Signature of Alternate Facility (or Generator) Menti Day year <br />Z <br />N18. <br />Hazartus bWaste Report Management Me" Codes (i.e., codes for hazardous waste treatment, disposal, and regd'mg systems) <br />0 <br />1 <br />2. 3. <br />4. <br />20. Designated Facil Onner or Operator: Certification of receipt of hazardous materials wmned by the manifest except as noted in Item 18a <br />1 <br />Pnntedfryped Name Sgmwm Month Day Yjr <br />EPA Form 8700-22 (Rev. 305) Previous editions are obsolete. DESIGNATED FACILITY To DESTINATION STATE (IF REQUIRED) <br />